Provider Demographics
NPI:1518065861
Name:WILSON, SAMUEL ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ERIC
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1436 VIA CASTILLA
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-2800
Mailing Address - Country:US
Mailing Address - Phone:714-456-7246
Mailing Address - Fax:714-456-8205
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:SUITE 810 CITY TOWER
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-7246
Practice Address - Fax:714-456-8205
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC283522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery